Cycle 1
Health 2024-08-29 · Fire 2024-08-29
31 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lancaster, OH
Luxe Rehabilitation And Care Center
2-star overall rating with 1-star inspections with Special Focus status with $70,768 in total fines with 31 recent health deficiencies
957 Becks Knob Road, Lancaster, OH
(740) 654-2634
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
172
Certified beds
Average residents
129
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David Oberlander
Operator or chain grouping
Approved since
1977-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 1 overall / 1 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,657
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.52
Baseline 19.13% · Performance 21.19% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Healthcare-associated infections
3.66
Baseline 8.13% · Performance 6.83% · Measure score 3.66 · Achievement 3.38 · Improvement 3.66
Total nurse turnover
0
Baseline 67.59% · Performance 80.69% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.32
Baseline 2.57 hours · Performance 2.83 hours · Measure score 0.32 · Achievement 0 · Improvement 0.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 13.11% · Lower 95% interval 7.62% |
| Discharge to community | 52.7% |
50.57%
2.1 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 44.04% · Lower 95% interval 44.3% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.24% |
95.27%
4 pts better
|
Numerator 131 · Denominator 132 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 1 · Denominator 132 |
| Discharge self-care score | 51.81% |
53.69%
1.9 pts worse
|
Numerator 43 · Denominator 83 |
| Discharge mobility score | 33.73% |
50.94%
17.2 pts worse
|
Numerator 28 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 6 · Denominator 132 · Adjusted rate 4.22% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 7.69% · Lower 95% interval 4.21% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 165 |
| Staff flu vaccination coverage | 24.55% |
42%
17.4 pts worse
|
Numerator 41 · Denominator 167 |
| Discharge function score | 55.42% |
56.45%
1 pts worse
|
Numerator 46 · Denominator 83 |
| Transfer of health information to provider | 94.59% |
95.95%
1.4 pts worse
|
Numerator 35 · Denominator 37 |
| Transfer of health information to patient | 97.22% |
96.28%
0.9 pts better
|
Numerator 35 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 3.28% |
25.2%
21.9 pts worse
|
Numerator 2 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.3% |
92.4%
10.1 pts worse
|
93.4%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 79.1% · Q3 79.8% · Q4 84.3% · 4Q avg 82.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 74.0% |
94.5%
20.5 pts worse
|
95.5%
21.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 74.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.3%
0.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.7% · Q3 4.0% · Q4 3.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 95.3% |
26.1%
69.2 pts worse
|
11.4%
83.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 100.0% · Q3 99.2% · Q4 88.7% · 4Q avg 95.3% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
6.2%
2.9 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.4% · Q3 8.6% · Q4 14.6% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.6% |
25.4%
4.2 pts worse
|
19.6%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 25.5% · Q3 31.8% · Q4 31.7% · 4Q avg 29.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
11.5%
0.3 pts worse
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 11.0% · Q3 12.2% · Q4 8.8% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.1% |
7.7%
2.6 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 5.2% · Q4 8.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
6.2%
1.9 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.8% · Q3 5.7% · Q4 4.9% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.5%
0.1 pts worse
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
21.7%
0.3 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 17.4% · Q3 22.4% · Q4 25.1% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
3.7%
1.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 0.8% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.2% |
78.1%
17.9 pts worse
|
81.7%
21.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.9% · Q2 60.7% · Q3 65.3% · Q4 75.0% · 4Q avg 60.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
12.5%
1.3 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 13.0% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.5% |
75.6%
16.1 pts worse
|
79.7%
20.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
25.1%
2.4 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 22.1% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-12 · Fire 2023-06-12
55 health deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-06-28 · Fire 2021-06-28
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-06-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-23
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-23
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-04-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-04
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-01-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-24
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-24
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-24
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-12
G · Actual harm
2024-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-10-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-11
G · Actual harm
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-11
G · Actual harm
2024-08-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-09
G · Actual harm
2024-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-29
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-29
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-06-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-05-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
E · Potential for more than minimal harm
2024-04-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-02-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-06
G · Actual harm
2024-01-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-12
D · Potential for more than minimal harm
2024-01-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-06
D · Potential for more than minimal harm
2023-12-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-03
G · Actual harm
2023-06-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-05
F · Potential for more than minimal harm
2021-06-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-08
D · Potential for more than minimal harm
2021-06-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-07-08
D · Potential for more than minimal harm
2021-06-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-07-08
D · Potential for more than minimal harm
2021-06-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-08
D · Potential for more than minimal harm
2021-06-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-07-08
D · Potential for more than minimal harm
2021-06-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-07-08
Penalties and ownership
What sits behind the stars
$53,691
2024-08-29
Fine
Fine · fine $53,691
Fine
$0
2024-08-29
Payment Denial
Payment Denial · denial start 2024-09-26 · 15 days
15 day denial
$17,077
2024-01-26
Fine
Fine · fine $17,077
Fine
Ownership
Wol Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Oberlander, David
5% Or Greater Indirect Ownership Interest · Individual
Wenger, Yehuda
5% Or Greater Indirect Ownership Interest · Individual
Oberlander, Sholem
5% Or Greater Indirect Ownership Interest · Individual
Dmt Spe I LLC
5% Or Greater Mortgage Interest · Organization
Hall, Staci
Operational/Managerial Control · Individual
Oberlander, David
Operational/Managerial Control · Individual
Oberlander, David
Corporate Officer · Individual
Wenger, Yehuda
Corporate Officer · Individual
Whitt, David
Operational/Managerial Control · Individual
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